Clinical Documentation Specialist RN

Where You’ll Work

St. Luke’s Health–Brazosport Hospital is located on a beautiful, 25-acre campus in Lake Jackson, Texas. Offering state-of-the-art diagnostic and comprehensive treatment services, our hospital is home to a 154-bed patient tower, level III trauma center, advanced cardiac care center, and full-service, multidisciplinary cancer center. Our team consists of over 100 board-certified physicians and nearly 600 highly skilled employees to meet our patients’ medical needs. South Brazoria County’s premier healthcare system, St. Luke’s Health–Brazosport Hospital is dedicated to providing quality care with compassion for the communities we serve.

Job Summary and Responsibilities

As a Clinical Documentation Specialist, you will provide critical expertise in medical record accuracy and integrity, profoundly impacting patient care quality and financial compliance.Every day you will expertly review clinical documentation, query physicians for clarity and specificity, educate providers on documentation best practices, and meticulously ensure all records accurately reflect the patient's severity of illness and complexity of care.To be successful, you will demonstrate outstanding analytical skills, strong knowledge of clinical coding guidelines, and a collaborative, detail-oriented demeanor, contributing to precise data, appropriate reimbursement, and improved patient outcomes.

• Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Initiates CDMP severity Worksheet for inpatients
• Formulate clinically credible documentation clarifications
• Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety

Job Requirements

Required

• Associates degree in Nursing required
• Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU, upon hire
• Registered Nurse: TX, upon hire